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Summary of Patient Protection and Affordable Care Act

Below is a brief summary of the Patient Protection and Affordable Care Act (P.L. 111-148).  Summary provided by Congressional Research Service and Thomas.Gov.  You can read more of the summary at http://thomas.loc.gov/cgi-bin/bdquery/z?d111:HR03590:@@@D&summ2=m&

Patient Protection and Affordable Care Act – Title I: Quality, Affordable Health Care for All Americans – Subtitle A: Immediate Improvements in Health Care Coverage for All Americans – (Sec. 1001, as modified by Sec. 10101) Amends the Public Health Service Act to prohibit a health plan (“health plan” under this subtitle excludes any “grandfathered health plan” as defined in section 1251) from establishing lifetime limits or annual limits on the dollar value of benefits for any participant or beneficiary after January 1, 2014. Permits a restricted annual limit for plan years beginning prior to January 1, 2014. Declares that a health plan shall not be prevented from placing annual or lifetime per-beneficiary limits on covered benefits that are not essential health benefits to the extent that such limits are otherwise permitted.

Prohibits a health plan from rescinding coverage of an enrollee except in the case of fraud or intentional misrepresentation of material fact.

Requires health plans to provide coverage for, and to not impose any cost sharing requirements for: (1) specified preventive items or services; (2) recommended immunizations; and (3) recommended preventive care and screenings for women and children.

Requires a health plan that provides dependent coverage of children to make such coverage available for an unmarried, adult child until the child turns 26 years of age.

Requires the Secretary of Health and Human Services (HHS) to develop standards for health plans (including grandfathered health plans) to provide an accurate summary of benefits and coverage explanation. Directs each such health plan, prior to any enrollment restriction, to provide such a summary of benefits and coverage explanation to: (1) the applicant at the time of application; (2) an enrollee prior to the time of enrollment or re-enrollment; and (3) a policy or certificate holder at the time of issuance of the policy or delivery of the certificate.

Requires group health plans to comply with requirements relating to the prohibition against discrimination in favor of highly compensated individuals.

Requires the Secretary to develop reporting requirements for health plans on benefits or reimbursement structures that: (1) improve health outcomes; (2) prevent hospital readmissions; (3) improve patient safety and reduce medical errors; and (4) promote wellness and health.

Requires a health plan (including a grandfathered health plan) to: (1) submit to the Secretary a report concerning the ratio of the incurred loss (or incurred claims) plus the loss adjustment expense (or change in contract reserves) to earned premiums; and (2) provide an annual rebate to each enrollee if the ratio of the amount of premium revenue expended by the issuer on reimbursement for clinical services provided to enrollees and activities that improve health care quality to the total amount of premium revenue for the plan year is less than a 85% for large group markets or 80% for small group or individual markets.

Requires each U.S. hospital to establish and make public a list of its standard charges for items and services.

Requires a health plan to implement an effective process for appeals of coverage determinations and claims.

Sets forth requirements for health plans related to: (1) designation of a primary care provider; (2) coverage of emergency services; and (3) elimination of referral requirements for obstetrical or gynecological care.

(Sec. 1002) Requires the Secretary to award grants to states for offices of health insurance consumer assistance or health insurance ombudsman programs.

(Sec. 1003, as modified by Sec. 10101) Requires the Secretary to establish a process for the annual review of unreasonable increases in premiums for health insurance coverage.

(Sec. 1004) Makes this subtitle effective for plan years beginning six months after enactment of this Act, with certain exceptions.

Subtitle B: Immediate Actions to Preserve and Expand Coverage – (Sec. 1101) Requires the Secretary to establish a temporary high risk health insurance pool program to provide health insurance coverage to eligible individuals with a preexisting condition. Terminates such coverage on January 1, 2014, and provides for a transition to an American Health Benefit Exchange (Exchange).

(Sec. 1102, as modified by Sec. 10102) Requires the Secretary to establish a temporary reinsurance program to provide reimbursement to participating employment-based plans for a portion of the cost of providing health insurance coverage to early retirees before January 1, 2014.

(Sec. 1103, as modified by Sec. 10102) Requires the Secretary to establish a mechanism, including an Internet website, through which a resident of, or small business in, any state may identify affordable health insurance coverage options in that state.

(Sec. 1104) Sets forth provisions governing electronic health care transactions. Establishes penalties for health plans failing to comply with requirements.

(Sec. 1105) Makes this subtitle effective on the date of enactment of this Act.

  1. September 8, 2011 at 3:27 am

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